Healthcare Provider Details

I. General information

NPI: 1053541102
Provider Name (Legal Business Name): 21DAYS2CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12032 N PENNSYLVANIA AVE
OKLAHOMA CITY OK
73120-7827
US

IV. Provider business mailing address

PO BOX 57366
OKLAHOMA CITY OK
73157-7366
US

V. Phone/Fax

Practice location:
  • Phone: 405-816-7735
  • Fax: 405-286-1380
Mailing address:
  • Phone: 405-816-7735
  • Fax: 405-286-1380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES O HALE
Title or Position: CHIEF OPERATING OFFICER
Credential: LPC
Phone: 405-816-7735